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SAN JOAQUIN COUN&LIC HEALTH SERVICES - ENVIRONMENTAL HEAL 0VSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> e — uex b <br /> -E FACILITY ADORE SS SITE PHONE k with AREA CODE <br /> a Neu*h R <br /> CITY 1ST T ZIP CODE B of TANKS y/ <br /> A �kyK y) (/J77 at SITE `r <br /> P �(�J� ,/ <br /> P APPLICANT/2It1ING NAME APPLICANT CONTACT NAME <br /> L I/WJ Tr uU{ L�'hes <br /> C rMAILING ADDRESS APPLICANT PHONE 3 WITH AREA CODE <br /> A <br /> N 0 �. <br /> TI CITY STATEI ZIP CODE TYPE of APPLICATION <br /> L/ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXX% I X%XX XXXX xxxx S XXXX%XXX <br /> CT FACILITY PENALTY FEES ASSESSED (If Applicable) XX%X %%%X %XXX I %XXX %XXX S %X%%XXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> S Tanks = 1988 1989 I 1990 1991 I 1992 1993 I 1994 1995 1996 1997 1998 <br /> F (multiply tl by fee for <br /> A each year applicable) XXX% X%XX XXX% XXX% XXX% I I I S <br /> I TANK PENALTY FEES ASSESSED I X%XX XXXX I x%XX I xxxx I%XXX I I I I I S <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y d Tanks_ x $8.00 1988 through 1993 (SS 6) 1993 through 1997 (356) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxX%%%XXXXX%X%XXX%XXXX XXXXXXXXXXXXXXXXX%X%XXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. %(s) <br /> 01 CLOSURE FEE = 578.00/hour (3 hours mini mum/TANK) I It TANK(S)- X 5234.00 I S <br /> S. <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. x(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mm I S 93('-('n <br /> P INSTALLATION PLAN CHECK (Plan Review 4 Construction Inspections)I TANK I.D. x(s) <br /> Ll ----]A <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 mini mum - S <br /> RREPAIR FEE (Workplan Review 3 Construction Inspections) I TANK I.D. Y(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.001hour (3 hours minimum/TANK) I N TANK(s) X 5234-00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I I I 1 <br /> 3 <br /> Ci CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 93(0•oV <br /> FOR OFFICE USE ONLY _ <br /> me.,r,mrIMM:.,—:!!mw!r..=.:rs=r. ..: .m^^ :! <br /> i SWEEPS )< COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK 9/CASH RECEIVED 3Y DATE RECEIVED <br /> t S <br /> 'mem•-. .-,�,.,.,T:�m��t., !r ti= ::. �:!_:re+ -m�:-�-:, <br /> 'iLtii,IiCeu3:3F,i-d!mEli_' <br /> e4 n n17 1QFVISFO 1-12-98) <br />